European Journal of Case Reports in Internal Medicine <p><strong>The&nbsp;<span class="HPblu">European Journal of Case Reports in Internal Medicine</span>&nbsp;</strong>is an official journal of the European Federation of Internal Medicine (EFIM), representing 35 national societies from&nbsp;<a href="">33 European countries</a>.&nbsp;<br><br>The journal’s mission is to promote the best medical practice and innovation in the field of acute and general medicine. It also provides a forum for internal medicine doctors where they can share new approaches with the aim of improving diagnostic and clinical skills in this field.&nbsp;<strong><br><span class="HPblu">EJCRIM&nbsp;</span></strong>welcomes high-quality case reports describing unusual or complex cases that an internist may encounter in everyday practice. The cases should either demonstrate the appropriateness of a diagnostic/therapeutic approach, describe a new procedure or maneuver, or show unusual manifestations of a disease or unexpected reactions. The Journal only accepts and publishes those case reports whose learning points provide new insight, contribute to advancing medical knowledge both in terms of diagnostics and therapeutic approaches. Case reports of medical errors, therefore, are also welcome as long as they provide innovative measures on how to prevent them in the current practice (Instructive Errors).&nbsp;<strong><br></strong>The Journal may also consider brief and reasoned reports on issues relevant to the practice of Internal Medicine, as well as Abstracts submitted to the scientific meetings of acknowledged medical societies.<br><br> <strong>EJCRIM</strong> is peer-reviewed with single-blind review and freely accessible to all.</p> SMC media s.r.l. - Via Giovenale 7, Milan - Italy en-US European Journal of Case Reports in Internal Medicine 2284-2594 <h3>Copyright and Disclosures</h3> <p>Every author must sign a copyright transfer agreement and disclose any financial or professional interest in any company, product, or service mentioned in an article. This authorization includes all submitted text including illustrations, tables, and other related materials.<br> If this submission contains any <strong>material that has been previously published</strong>, this authorization <strong>must also be accompanied</strong> by all necessary Permission to Reproduce Published Material" forms completed by the current copyright owner. If this submission contains any <strong>previously unpublished material</strong> for which the person(s) signing this form <strong>does not own copyright</strong>, an additional "Authorization to Publish" form is required from each corresponding copyright owner.</p> <h3>Copyright Transfer Declaration</h3> <p>(this may be included as a word document with your manuscript submission)<br> I confirm that I am the current copyright owner of the material described above and hereby transfer and assign to the European Journal of Case Reports in Internal Medicine (EJCRIM) all copyrights in and to the material for publication throughout the world, in all forms and media, in English and in any other language(s). Such transfer includes publication in this and all future editions of the publication named above and in any other publications (including slide collections and any other nonprint media) of EJCRIM and gives EJCRIM the sole authority to grant rights for use of the material by others.<br> I waive EJCRIM from any liabilities connected to the incorrect copyright statement.<br>The copyright agreement form can be downloaded <a style="font-weight: bold;" href="/documents/EJCRIM_Copyright_auth.pdf">HERE</a> or requested to the editorial office <a style="font-weight: bold;" href=""></a></p> A rare case of a second degree atroventricular block and Takotsubo syndrome <p><em>Background:</em> Takotsubo cardiomyopathy is characterized by a transient left systolic dysfunction that can mimic an acute myocardial infarction. The presence of atrioventricular (AV) block associated with Takotsubo is rare, but in recent years a few number of cases has been reported</p> <p><em>Methods:</em> We present the case of a 77-year-old woman presenting with a second degree atrioventricular block and Takotsubo syndome.</p> <p><em>Results:</em> The diagnosis of Takotsubo syndrome was based on the echocardiogram changes and in the absence of obstruction of the coronary arteries in coronary angiography</p> <p><em>Conclusions:</em> We describe a case of a patient that had a diagnosis of Takotsubo syndrome and AV conduction defect. &nbsp;These rarely occur simultaneous. When they do, this poses a dilemma regarding the implantation of the pacemaker.</p> Raquel Costa Joana Fontes Tiago Mendes Joana Faria Silva Bárbara Sousa Copyright (c) A rare case of hypophosphatemic osteomalacia in von Recklinghausen neurofibromatosis <p><strong>Background</strong></p> <p>The neurofibromatoses type 1 (NF1), also known as the "von Recklingausen disease", is one of the most common hereditary autosomal disorders. Osteomalacia in neurofibromatosis type 1 is very rare tumor-induced osteomalacia, fibroblast growth factor 23 is usually incriminated.</p> <p><strong>Patients and methods</strong></p> <p>We report a case of a patient with a history of von Recklinghausen neurofibromatosis who presented with hypophosphatemic osteomalacia.</p> <p><strong>Results</strong></p> <p>The patient was treated with high dose of calcitriol and oral phosphate. The evolution was marked by clinical improvement.</p> <p><strong>Conclusion </strong></p> <p>Even though it is a rare entity, we must consider the diagnosis of hypophosphatemic osteomalacia in patients with neurofibromatoses, in order to adopt the appropriate treatment.</p> yasmine makhlouf Soumaya Boussaid Houda Ajlani Samia Jemmali Sonia Rekik Hela Sehli Mouhamed ELeuch Copyright (c) The Meaning of SARS-CoV-2 antibodies in a patient with systemic reaction to the mRNA-1273 SARS-CoV-2 vaccine after previous natural immunization <p>Objectives: There is limited experience regarding the meaning of SARS-CoV-2 antibodies after vaccination in patients with naturally acquired immunity.</p> <p>Methods: We describe the case of a patient who received the first dose of the mRNA-1273 SARS-CoV-2 vaccine 6 months after his recovery from moderately severe COVID-19.</p> <p>Results: Our patient had a positive nucleocapsid SARS-CoV-2 IgG/IgM titer with 78.7 multiple of cut-off indicating persistent humoral immune response 6 months after infection. After vaccination, he developed prolonged systemic symptoms (fever, fatigue, nausea, diarrhea, and myalgia) for a duration of 6 days.</p> <p>Conclusion: SARS-CoV-2 nucleocapsid antibodies provide information about naturally acquired immunity. For the assessment of immune response to vaccination, the measurement of the SARS-CoV-2 spike antibody titer before and after vaccination is essential. Patients with naturally acquired immunity might develop a prolonged systemic reaction to the first dose of the mRNA-1273 SARS-CoV-2 vaccine.</p> Lorraine Sazgary Andrea Meienberg Christoph T. Berger Michael Mayr Copyright (c) Missed Diagnosis of Subarachnoid Hemorrhage <p>Herein, we describe some strategies to rule out SAH other than radiological examination, such as lumbar puncture and “revisiting tests in time-axis perspective” and investigate the biases which affected the clinical decision-making. A 79-year-old woman presented with left retro-orbital pain, headache, and blurred vision. Based on the negative radiological tests, life-threatening diseases like SAH were ruled out and outpatient follow-up was planned. However, the patient returned to the hospital that night because of progressively declining consciousness and was diagnosed with SAH by a head computed tomography. The diagnosis of SAH is often challenging, especially in cases with negative radiological results.</p> Teiko Kawahigashi Taro Shimiszu Takashi Kawabe Yoshitoshi Kida Kazunao Watanabe Copyright (c) Helicobacter pylori INFECTION ASSOCIATED WITH IMMUNE THROMBOCYTOPENIA: LESS IS MORE <p>Immune thrombocytopenia (ITP) results from immune-mediated destruction of platelets and/or megakaryocytes, leading to a low platelet count. Despite multiple aetiologies, interestingly, there is a strong evidence for an association between infection with <em>Helicobacter pylori</em>(Hp) and ITP.</p> <p>The authors present a case report of a 57-year-old man who presented dyspeptic symptoms and severe thrombocytopenia The etiologic study revealed an Hp infection and its eradication led to the resolution of the thrombocytopenia.</p> Carolina Amado Mariana Silva Leal Gisela Ferreira Margarida Cruz Copyright (c) A Case Report of a Patient with Alcoholic Hepatitis Benefits from Oral Budesonide <p>Introduction: Alcoholic hepatitis (AH) is a kind of alcoholic liver disease (ALD) caused by heavy and prolonged alcohol consumption. AH is between fatty infiltration to cirrhosis by the range of liver injury of alcohol. Abstinance of alcohol is the major treatment method in ALDs, besides corticosteroids are a treatment option in AH by the guidence of the Maddrey Discriminant Function score (MDF).</p> <p>Case description:&nbsp; A 56-year-old man with multiple comorbidities admitted to the hospital with the complaint of jaundice, was diagnosed as AH. His MDF at admission calculated as 38 and patient has given oral budesonide as main therapy instead of methylprednisolone/prednisolone (M/P) due to his diabetes mellitus and cataract. His MDF score was 19,9 at discharge. Thus, his total bilirubin levels in connection with other clinical symptoms attributed to alcoholic hepatitis were also improved with oral budesonide theraphy.</p> <p>Conclusion:&nbsp; Because of cataract disease, prefering budenoside can reveal better outcome instead of M/P in the treatment of AH.</p> <p>Keywords: Alcoholic hepatitis, the Maddrey Discriminant Function score, Budenoside, Methylprednisolone/Prednisolone&nbsp;</p> MUSTAFA YAKARIŞIK Ahmet Cumhur Dülger Muhammed Ali Ayvaz Cafer Akköz Ayfer Ugış Copyright (c) Takotsubo syndrome as consequence of ischemic stroke – Case Report <p>Takotsubo’s cardiomyopathy is characterized by transient left ventricular systolic dysfunction that mimics acute myocardial infarction, in the absence of coronary stenosis. Normally occurs after an emotional or physical stress. Ischemic stroke of the insular region is often associated with this syndrome. The authors present a case of a 82 year-old woman that was admitted with a ischemic stroke of the right frontal and insular region. One day after her admission, the patient complained of chest pain and dyspnea. The exams that the patient underwent suggested she suffered from Takotsubo syndrome. To make possible this diagnosis, after 2 weeks she had normalization of every exam, particularly the echocardiogram that return to normal.</p> <p>Takotasubo is normally a benign condition, but it can lead to congestive heart failure and sudden death. It is important to promptly detect and manage this condition.</p> Raquel Costa Joana Fontes Tiago Mendes Joana Faria Silva Bárbara Sousa Copyright (c) Muscular polyarteritis nodosa: A case series study of six patients <p><em>Introduction:</em> In a subset of polyarteritis nodosa known as muscular polyarteritis nodosa (MPAN), the disease process mostly remains limited to the muscle. We herein report on six patients with MPAN, in whom we investigated the clinical features of this disease.</p> <p><em>Materials and Methods:</em> We examined six patients who visited our department between April 2010 and October 2019, and had a confirmed diagnosis of MPAN. MPAN was diagnosed on the basis of symptoms, physical findings, results of laboratory tests and imaging studies, biopsy findings, and referral to rheumatologists. All six patients met the diagnostic criteria for PAN. The diagnosis of MPAN was confirmed by at least two specialists, including at least one rheumatologist. We collected data from medical records.</p> <p><em>Results:</em> Our data revealed that the clinical features of MPAN include fever, myalgia, muscle tenderness without restricted ankle joint range of motion, elevated C-reactive protein levels, normal creatine kinase levels, and high-intensity lesions on magnetic resonance imaging of the site of pain.</p> <p><em>Conclusion:</em> The clinical features of MPAN include fever, myalgia, muscle tenderness without restricted joint range of motion, elevated CRP levels, and normal CK levels. In the presence of such features, MPAN should be suspected and MRI of the lower extremities is recommended. In cases with the specific MRI findings described above, muscle biopsy should be performed to correctly diagnose and treat this rare condition.</p> <p>&nbsp;</p> Fumitoshi Fukuzawa Kiyoshi Shikino Yosuke Yamauchi Daiki Yokokawa Akiko Ikegami Takanori Uehara Masatomi Ikusaka Copyright (c) Fahr’s Syndrome – A Case report <p>Fahr’s syndrome is an uncommon neurodegenerative disorder, characterized by bilateral and extensive deposition of calcium in the basal ganglia <sup>1,2,3</sup>. The most common symptoms are neuropsychiatric manifestations and motor symptoms. Idiophatic hypoparathyroidism has been implicated in the majority of the cases.</p> <p>We present the case of a 66-year-old female with Fahr’s syndrome due to primary idiopathic hypoparathyroidism. The diagnosis was based on clinic signs and symptoms of hypocalcemia, radiologic findings of calcifications deposite on basal ganglia and laboratory evidence of hypoparathyroidism.</p> <p>Although rare, Fahr’s syndrome must be kept in mind and appropriate treatment should be aplied in order to stop it’s progression and improve the clinic symptoms and signs.</p> Raquel Costa Copyright (c) A visible and palpable, but can be missed cause of acute upper airway obstruction <p>An 85-year-old woman presented with gradually progressive dyspnoea. The patient was initially managed as severe asthma; however, the patient’s condition deteriorated, and the patient was intubated. After excluding other airway and pulmonary diseases, acute upper airway obstruction by a diffuse goitre was diagnosed. The patient received a total thyroidectomy, and the pathological findings were consistent with benign Hashimoto’s thyroiditis. The patient was discharged home without any complications. Physicians should consider goitre as a cause of acute respiratory failure in patients with goitres which have characteristics such as diffuse, extending to substernal, and surrounding almost the entire trachea.</p> Shintaro Kakimoto Yukinori Harada Taro Shimizu Copyright (c)